What should a falls risk assessment include?: A Comprehensive Guide

Oct 21, 2025 4 min read •

Geriatrics Health Safety

According to the Centers for Disease Control and Prevention (CDC), over one in four older adults falls each year, making falls a leading cause of injury among this demographic. To effectively mitigate this risk, a thorough falls risk assessment is crucial, as it identifies and addresses the multiple, often interconnected, factors that can contribute to a fall.

Quick Summary

A comprehensive falls risk assessment evaluates intrinsic and extrinsic factors affecting an individual's fall likelihood. It involves a detailed medical and fall history, a review of medications, a physical examination focusing on balance and gait, a functional assessment, and an inspection for environmental hazards, such as clutter and poor lighting.

Key Points

History is a Key Indicator: A detailed history of past falls is the single best predictor of future fall risk.
Medications are a Major Factor: Many medications, especially psychoactive drugs, can increase fall risk by affecting balance and cognition.
Mobility and Balance are Critical: Assessments like the Timed Up and Go (TUG) test are essential for evaluating functional mobility and balance.
Home Environment is Controllable: Modifying environmental hazards, such as removing loose rugs and improving lighting, is a crucial intervention.
Assess Both Intrinsic and Extrinsic Factors: A comprehensive assessment considers both patient-specific (intrinsic) and environmental (extrinsic) risk factors.
Screening is Recommended Annually: Guidelines recommend annual fall risk screening for older adults (65+) or whenever a patient presents with a fall.

Key components of a comprehensive falls risk assessment

A comprehensive falls risk assessment is a multifactorial process that considers an individual's physical condition, medications, functional abilities, and living environment. Healthcare providers, including physicians, nurses, and physical therapists, typically conduct these assessments. The following components are essential for a thorough evaluation:

Medical and fall history

One of the best predictors of a future fall is a history of previous falls. A detailed medical and fall history is therefore a critical starting point. This includes documenting the number of falls within the last year, the circumstances of each fall (location, time, activity), and any injuries sustained. Information on premonitory symptoms, such as dizziness or palpitations, and the ability to get up afterward is also vital. Providers should also screen for chronic conditions like arthritis, Parkinson's disease, and diabetes, which can impact mobility and sensation. Fear of falling is another important factor to assess, as it can lead to reduced activity, muscle deconditioning, and, paradoxically, a higher risk of falls.

Medication review

A medication review is a critical step, as many drugs can increase fall risk. Psychoactive medications, such as sedatives, antidepressants, and antipsychotics, are significant predictors of falls because they can cause drowsiness, affect balance, and alter mental status. Other medications, including certain antihypertensives and diuretics, can lead to postural hypotension, a drop in blood pressure when standing that causes dizziness. A healthcare provider or pharmacist should review all medications, including over-the-counter drugs and supplements, to identify those that increase risk. This review may lead to dose adjustments or switching to safer alternatives.

Physical examination

A fall-focused physical examination is a cornerstone of the assessment. It typically includes:

Orthostatic vital signs: Measuring blood pressure and heart rate while the patient is lying, sitting, and standing to check for postural hypotension.
Gait and balance evaluation: Using standardized tests to evaluate walking and stability. Common tools include the Timed Up and Go (TUG) test, the 30-Second Chair Stand Test, and the 4-Stage Balance Test.
Musculoskeletal examination: Assessing muscle strength, tone, range of motion, and any issues affecting the back and lower extremities.
Neurological examination: Checking for sensation, reflexes, and higher neurological function related to balance and coordination.
Cognitive screening: A brief cognitive test, like the Mini-Cog, is used to identify impairment, which can affect judgment and spatial awareness.
Vision assessment: Evaluating visual acuity, as poor vision significantly affects depth perception and stability.

Functional assessment

This part of the assessment evaluates a person's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Understanding functional limitations helps determine the circumstances and location of falls. For instance, individuals with functional limitations may be more prone to falling at home during routine tasks, whereas more active individuals might fall on stairs or when reaching. Assessment may involve observing the patient's performance of specific tasks or using standardized tools like the Berg Balance Scale.

Environmental assessment

Many falls are caused by external factors in the individual's surroundings. An environmental assessment, often conducted by an occupational therapist, involves a home safety checklist to identify and address hazards. Key areas of focus include:

Pathways: Clearing obstacles, loose rugs, and clutter.
Flooring: Checking for slippery surfaces, uneven transitions, and loose floorboards.
Lighting: Ensuring adequate lighting, especially in hallways, stairways, and bathrooms.
Bathrooms: Installing grab bars, non-slip mats, and raised toilet seats.
Stairs: Providing sturdy handrails on both sides of staircases.
Footwear: Checking that shoes are supportive and have non-slip soles.

Intrinsic vs. extrinsic fall risk factors


Assessment Category	Intrinsic (Patient-Specific) Factors	Extrinsic (Environmental/External) Factors
Physical & Sensory	Age-related changes (muscle weakness, slower reflexes), balance disorders, impaired vision and hearing, foot pain, chronic diseases (Parkinson's, arthritis)	Poor footwear (slippery soles, high heels), lack of assistive devices (cane, walker)
Medical	Certain medications (sedatives, antidepressants, blood pressure drugs), postural hypotension, cognitive impairment (dementia, confusion)	Polypharmacy (taking multiple medications), incorrect use of medication
Behavioral & Psychological	Fear of falling, risk-taking behavior, depression	Lack of physical exercise or balance training, social withdrawal due to fear of falling
Home Environment	Difficulties with activities of daily living (ADLs)	Clutter and obstacles, poor lighting, slippery floors or rugs, uneven outdoor surfaces

Conclusion

A falls risk assessment must be a comprehensive and multifaceted evaluation to be effective. By addressing intrinsic factors, such as physical health and medication use, in conjunction with extrinsic factors like environmental hazards, healthcare professionals and caregivers can create a holistic prevention plan. The use of standardized tools and checklists ensures that all potential risks are systematically identified. Ultimately, a thorough assessment and subsequent intervention plan can significantly reduce the risk of falls, helping individuals maintain their independence and quality of life. It's a proactive approach to safety that prioritizes early detection and tailored preventive measures for those most at risk.

How the CDC's STEADI initiative helps

The Centers for Disease Control and Prevention (CDC) developed the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative to help healthcare providers implement clinical practice guidelines for fall prevention. It provides resources for a three-step process: Screen, Assess, and Intervene. STEADI includes validated screening questions and reliable assessment tools like the Timed Up and Go (TUG) test to help guide decision-making. By using a structured, evidence-based approach, healthcare providers can better integrate fall prevention into routine patient care. For more information, visit the CDC's STEADI website.

Frequently Asked Questions

Common risk factors for falls include intrinsic factors, like age-related changes, medication side effects, chronic diseases, and balance problems, as well as extrinsic factors, such as environmental hazards like poor lighting, slippery floors, and clutter.

For older adults aged 65 and over, an initial falls risk assessment should be performed at least annually or anytime a fall occurs. In institutional settings, it is often done on admission or when there is a change in the patient's health status.

The Timed Up and Go (TUG) test is a simple screening tool that measures a person's functional mobility by timing how long it takes them to stand from a chair, walk 10 feet, turn around, walk back, and sit down. Taking 12 seconds or more to complete the test indicates a higher fall risk.

Yes, a medication review is a key part of fall prevention. A healthcare provider may recommend stopping unnecessary medications, reducing doses, or switching to safer alternatives for drugs known to increase fall risk, such as sedatives or certain blood pressure medications.

An environmental assessment identifies and helps modify potential hazards in the home. This includes removing loose rugs, ensuring good lighting, installing grab bars in bathrooms, and securing handrails on stairs to create a safer living space.

Falls risk assessments are typically conducted by various healthcare professionals, including physicians, nurses, physical therapists, and occupational therapists. The specific professional involved often depends on the setting and the nature of the identified risks.

After a fall, immediate evaluation by a nurse or other healthcare professional is necessary to assess and monitor for injuries. This is followed by an investigation into the circumstances of the fall and an in-depth falls assessment to prevent future incidents.

References

Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.